Permission Form – General Release/Hold Harmless Agreement for ...

Permission Form – General Release/Hold Harmless Agreement for St. Matthew’s
Episcopal Church, Vacation Bible School, July 8-12, 2013.
CHILD’S NAME__________________________________________________________
As the parent or legal guardian of ______________________________________ I
agree to the following:
The child listed above has permission to participate in the St. Matthew’s
Episcopal Church Vacation Bible School, from July 8 – 12, 2013.
Without the release and permission of the parent, the above child cannot
participate in St. Matthew’s Episcopal Church Vacation Bible School.
I, the undersigned, request that the Church and Children’s ministry allow the
child to participate in the activity and in consideration thereof, agree to hereby
release and forever discharge the Church, Children’s ministry, their offices,
directors, employees, agents and any parties volunteering on behalf of the
church from all actions, claims, damages of any kind growing out of related
activity.
I acknowledge that this is a full and complete release for all injuries and
damages which the above child may sustain as a result of participating in the
activities.
I authorize the treatment of the child by a qualified and licensed medical
doctor in the event of an emergency which, in the opinion of the attending
physician, may endanger his/her life, cause disfigurement, physical impairment,
or undue physical discomfort if delayed, while said minor is participating in the
activity – including transportation to and from the site. The authority is granted
only after a reasonable attempt has been made to contact me, the parent or
guardian.
Any required medicines to be delivered during VBS. All drugs need to be in their
original package with prescription information.
YOUR SIGNATURE: _______________________________________date_______________

REGISTRATION FOR ST. MATTHEW’S VBS
Child’s Full Name____________________________Nickname _____________
Child’s Age___________Grade enrolled in for Fall 2013__________________
Parent/Guardian’s Name_____________________________________________
Address______________________________________________________________
City______________________________State_________________Zipcode_______
Home Telephone Number:_______________Cell Number:_________________
Home Email Address:_____________________________________________
Home Church (if any) _____________________________________________
Emergency contact person and phone numbers:
________________________________________________________________________
PICK UP INFORMATION: Person responsible for picking this child up each
day
Name:
______________________________________Phone:_________________________
Relationship to child___________________________________________________
PLEASE LIST ANY ALLERGIES OR OTHER CONCERNS THE VBS STAFF SHOULD BE
AWARE OF:
_______________________________________________________________________
The child’s physical limitations are:
________________________________________________________________________
The child’s medications are _______________and taken__________________,
______________________________________________ give permission for St.
Matthew’s Episcopal Church to use the image, voice, quote, or video of
my child, ____________________________________________. St. Matthew’s
Episcopal Church may the image, voice, quote or video of my child at
their discretion, including, but not restricted to, the website, brochures or
other promotional material.
YOUR SIGNATURE:___________________________________Date_______________
PLEASE FILL OUT THE BACK OF THIS FORM